Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 22
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27SECTION 12: SUPPORTING DOCUMENTS
This section lists the documents that, if applicable, must be submitted with this completed enrollment
application. If you are newly enrolling, adding a new location, reactivating or revalidating, you must provide
all applicable documents. For changes, only submit documents that are applicable to the change requested.
All enrolling DMEPOS suppliers are required to furnish information on all federal, state, and local professional
and business licenses, certifications, and/or registrations required to practice as a DMEPOS supplier in the
state of the business location as reported in Section 1A. Check the NSC MAC website for further guidance
on supplier requirements. You are responsible for furnishing and adhering to all required licensure and/or
certification requirements, etc. for the supplies/services you provide.
The enrolling DMEPOS supplier may submit a notarized Certificate of Good Standing from the DMEPOS
supplier’s business location’s state licensing/certification board or other medical association, in lieu of copies of
the requested documents. This certificate cannot be more than 30 days old.
If the enrolling DMEPOS supplier has had a previously revoked or suspended license, certification, or
registration reinstated, attach a copy of the reinstatement notice with this application.
MANDATORY FOR ALL NEW APPLICATIONS AND/OR ADDITIONAL LOCATIONS
Copies of all federal, state, and/or local (city/county) professional and business licenses, certifications and/or
registrations for applicable specialty supplier types, products and services
Copy of Certification of Insurance for comprehensive liability policy
NOTE: The NSC MAC must be listed as a certificate holder with the NSC MAC’s full address (Post Office Box
address listed on p. 4 of this application)
Written confirmation from the IRS confirming your Tax Identification Number and Legal Business Name
provided in Section 1B (e.g., IRS Form CP-575)
NOTE: This information is needed if the applicant is enrolling a professional corporation, professional
association, or limited liability corporation with this application or enrolling as a sole proprietor using an
Employer Identification Number.
Completed Form CMS-588, Electronic Funds Transfer Authorization Agreement. Include a voided check.
Copy of receipt of payment of application fee from
MANDATORY, IF APPLICABLE
Copy of IRS Determination Letter, if supplier is registered with the IRS as non-profit (e.g., IRS Form 501(c)(3))
NOTE: Government owned entities do not need to provide an IRS Form 501(c)(3).
Copies of all final adverse legal action documentation (e.g., notifications, resolutions, and reinstatement
letters)
If Medicare payments due a supplier are being sent to a bank (or similar financial institution) where the
supplier has a lending relationship (that is, any type of loan), the supplier must provide a statement in writing
from the bank (which must be in the loan agreement) that the bank has agreed to waive its right of offset
for Medicare receivables.
Copy of delegated official’s W-2 if one has been designated
Copy of your bill of sale if you purchased an existing DMEPOS supplier with an active Medicare supplier
billing number
Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement, if you want to be a
participating supplier
Copy of Surety Bond
Copy of attestation letter for government entities and tribal facilities
Copy of receipt of payment of application for revalidation or reactivation from
CMS-855S (05/16)
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